Posted by Rick on September 23, 2000, at 3:21:26
In reply to Re: Social Phobia Cocktail -- WOW!!!, posted by Billb on September 22, 2000, at 16:16:25
> These sound like exciting and promising cocktail combinations. Am I the only one who has a Pdoc who is not open to suggestions and is very non-agressive in trying new meds? At my present rate, it would take my Pdoc years to agree to evolve thru trials of these meds. What I currently get when I meet with him every three months is, "if it doesn't improve soon I'll up your paxil again."
>
> Any tips on how to state my desires to my Pdoc to trial differnt meds. so that I can quickly identify a cocktail that works for me? Or is finding a new Pdoc the only solution. For me, that would mean driving out of this small town to an urban area.
>
> By the way, thanks for the great posts!That's a tough one to answer, since every pdoc's different. I'm still using my first one, who I picked out from the phone book, believe it or not. Even though he was expensive and out-of-network (i.e., lower insurance reimbursement), I was attracted by his listing which said "Phd, MD, 25 years experience" and "Psychobiologically Oriented, Psyhoanalytically Aware". I had done plenty of research, and I frankly wanted someone who I knew would be med-oriented and not bound by convention. (It turns out the "biological" part also involved a lot of dietary advice and an "insistence" that I lose at least 50 pounds, i.e., drop to 180. And as it turns out, his card says simply "psychoanalytically aware" -- what happened to "biological"?)
When he spent 3/4 of our second session explaining the history of the medication he was about to give me, and why it receives a bum rap, I knew I had probably selected the guy I wanted. The medication he gave me was Nardil, plus as-needed Xanax. I don't get the impression Social Anxiety treatment is really a specialty of his (even though the usually-avoided Nardil HAS proven to be the best AD for Social Phobia).
Frankly, he has about the worst "couchside" manner I could imagine, and is very conservative in some ways (including one GOOD one: the "start low, go slow" philosophy"). I saw him at least once a month (if the expense isn't a big difficulty, that may be one way for you to move thigs along more quickly). After "playing along" with several trials of drugs that made little sense for Social Phobia, I had a very troubling work experience, and went to him distraught that day (actually, I think I was overstating my anguish, but I WAS frustrated), and he gave me Tranxene (!). It was soon after this that I came back and politely but firmly said that nothing was working thus far, and that I wanted to try the Klonopin that I had read was so very effective for Social Phobia in placebo-based studies. He grudgingly said "O.K." (remember, this guy is no Social Phobia expert", and I was soon filled with delight that something was actually working -- WELL and QUICKLY -- and with no side effects except good ones (!) after the first week.
Since then, it's been mainly "stick with whatever works for you (Klonopin). Now, what have your dreams been lately". The other thing we've done in the last year is fine-tune. I've been pretty aggressive about what I wanted to add in an attempt to "go for the gold", although I certainly gave his ideas a try. Fortunately (but incorrectly, except perhaps for benzos), this guy expects patients to start showing response to a drug very quickly if its going to work, regardless of disorder. Thus, we could move on fairly quickly, after one or two quick dosage-adjustment attempts.
Our ideas on various Klonopin+ combos have ranged from very convergent to very divergent. I believe he was hoping I might be able to replace the Klonopin. It's NOT that he's benzophobic; he simply prefers AD's and other anti-anxiety drugs like BuSpar abd Neurontin. One thing that has worked in my favor, in addition to the frequent visits (that have become infrequent since I've found my powerful Anti-Social Phobia cocktail), is that I came armed with plenty of knowledge and research about the meds I wanted to try. It was hardest to get him to prescribe Provigil, which he had never used, and which he said had virtually no track record (True, in the U.S., anyways). But after I was looking for something to make more "up", and had failed trials of selegiline and Wellbutrin (with the Celexa I was taking then) due to increased anxiety, he wanted me to try Ritalin. I really didn't want Ritalin (he's a big fan), and kept talking to him about the supposedly gentler, non-addicting, and less side-effect-prone (NONE for me) stimulant Provigil. He had been intrigued by stories about the (French?) government giving soldiers Provigil in Desert Storm. But even as I pummelled him with research, and even as he was astounded that Caremark had sent outa notice advocating the use of this very-expensive drug over traditional amphetamine-based anti-narcoleptics, he was starting to write a prescription for Ritalin. But I kept insisting, and he said, "O.K., if you want to be the guinea pig, even though you're already doing pretty well...". I'm REALLY glad I prevailed there.
Sorry for getting carried away with the details of the story (actually, that was just a topline review!). Anyways, if you have to stick with the pdoc you have and you're not getting what you want, I would try to (1) Go as often as possible, and note your lack of any (good) response, especially after a dosage increase. (2) Inundate him with reputable research! If you want to try Klonopin, show him those Duke University abstracts I gave Donna Lynn the links to, addressing both high placebo-controlled efficacy, safety in long-term use and discontinuation, and continued effectiveness at maintenance doses. Better yet, obtain and print a copy of the complete journal articles. These are rigorous, reputable studies by Dr, Davidson of Duke, recognized in the psychiatric community as one of the nations pre-eminent Social Phobia experts. (Fyi, today Dr. Davidson goes along with the recommendation of an SSRI as the first-line treatment, even though none of the Paxil cntrolled studies have come anywhere near Klonopin's 78% response rate.) There are also studies available showing Serzone to be highly effective in Social Phobia, although they were not placebo controlled (3) Emphasize your continued mental (and side effect?) distres. If he's totally unresponsive, exaggerate or be more dramatic in your presentaton (4) Be politely pushy (of course, this became easier for me after I was aready on Klonopin!) (5) When push comes to shove, tell him/her that while you apreciate his/her efforts, you have researched other strategies, and that at this point you will have to look elsewhere, even if it means leaving town, and so you want to begin carefully weaning off the Paxil. (In the doc's defense, many patients do not see their biggest increase in AD anti-anxiety benfits until a full 8 to 12 weeks at a theraputic dose.) If you need to go back on Paxil, almost any GP will give it to you, although you might have to explain to them what Social Phobia is, and that Paxil has an FDA-approved indication for treatment of SP.
As for endorsing the foreign meds, I highly doubt your guy would go along. While I'm not too cofortable with the idea myself, you've seen that many on ths board seem to have had great success with legally-ordered (I think?) meds.
Good Luck,
Rick
poster:Rick
thread:36517
URL: http://www.dr-bob.org/babble/20000905/msgs/45105.html